Getting the most out of current  treatments

Peter Hajek

Do we need to get more out of current treatments?

Treatments we have are effective, but with a large scope for improvement

Stop-smoking services have some 15% long-term quit rate, much better than 5% for unaided quit attempts, but still helping only a minority of clients

Possible improvements

Do not provide ineffective treatments

Keep up-to-date and use new treatment variations when available

Participate in research

Ineffective treatments: Examples from secondary care

Stop-smoking interventions in acute and maternity services:

Review of effectiveness

Report for the

National Institute for Health and Clinical Excellence

Katie Myers, Hayden McRobbie, Peter Hajek

25 April 2012

19,520 abstracts screened

179 papers included

Method

Summary of results

Brief interventions and interventions with follow-up under 4 weeks are not effective, with or without meds

Interventions providing support for over 4 weeks in combination with medications are effective

Front-line healthcare staff should focus on referring smokers to SSS

And yet Some services still focus on training

front-line staff to deliver brief interventions known to be ineffective

Referrals to SSS from hospitals remain low. Lack of organisational support, unclear referral pathways, obsolete training templates

See survey of UK services by B. Proctor

To join the Secondary Care Services Network

E-mail Barnie Proctor on

b.proctor@qmul.ac.uk

Changing profile of UK smokers

When smoking rates are high, there are many smokers who benefit from brief interventions

When ‘low-hanging fruit’ is gone, remaining smokers are increasingly ‘treatment resistant’ (mental health problems, re-attenders, etc.)

New priorities: Intensive treatments and harm-reduction approaches

Conclusions

Smokers seeking help should be referred for specialist intensive treatment rather than for brief interventions

Such treatment should be the core focus of stop-smoking services

Can we do better with medications we have?

The field has been remarkablyconservative

NRT did not improve for over 30 years !!! Varenicline: no change since launch 7

years ago

The curse of medicinal licensing stops product development stops variation in use

Old NRT products

UK is more liberal with NRT than other countries

Our licensing allowsExtended usePre-loadingCombinations and increased

dosing

Using NRT for longer

Using NRT for longer

Cochrane: Use for 8 or cca 12 weeks, NS New(ish) study: Patches for 2 or 6 months

2M nicotine patches + 4M placebo in controls Effect at 6 months (continuous abstinence 13% vs

19%) No effect at 1 year: 1% vs 0.7% (14% vs 15% 1-

week abstinence) Different from use for RP

Schnoll et al. Ann Intern Med 2010,152,144-151

Using NRT prior to quitting

Using NRT prior to quitting (?)

First review +++ *; second review: little effect ** NIHR study (Aveyard et al) on-going; patch or

no patch for 4 weeks pre-quit Used by some with priority groups to facilitate

quitting or reduce harm Anecdotally useful, licensing allows it

* Shiffman&Ferguson (2008) Addiction 103:557-563

** Lindson&Aveyard (2011) Psychopharmacology 214:579-592.

Should you ask smokers to cut down when pre-loading?

In theory, this could be counterproductive. The aim is to make cigarettes less rewarding via extinction process, cutting down is likely to make remaining cigs more rewarding

Tailor NRT dose to response

Tailor NRT dose to response (?)

Increase dose during pre-loading until cig consumption and enjoyment are affected

(‘Non-reactor’ into ‘reactors’) Licensing allows it (to a degree) Anecdotally effective Studies needed with high dosing Services willing to help – e-mail me

E-cigarettes (EC)

E-cigarettes (?) The most promising development by far,

needs time to evolve to kill off cigarettes Recent UK ruling will prevent that after 2016 But EC are almost certainly good enough

already as treatment, though No RCTs yet Already used in priority groups, service

guidance needed

Good nicotine delivery and craving relief (Vansickel et al, Addiction 2012)

20 smokers

6 x 10-puff

Matches cigs in experienced users Vansickel & Eissenberg Nicotine & Tobacco Research 2012

8 experienced e-cig users, abstained overnight

Used their own EC

10 puffs and then 1 hour of ad-lib use

40 smokers who did not want to quit EC to reduce smoking

At 6-month 23% stopped smoking Another 46% reduced by 50% or more

Helps smokers unwilling to quit (Polosa et al BMC Public Health 2011)

‘If I had a brother, or a child, or friend who smoked, I would try to get them thinking about e-cigs’

Lynn Kozlowski, 2013

What we tell patients attending our clinics and asking about EC?

Do you recommend using them to quit? For now we prefer you to use NRT or Champix, but

fine to try EC in addition to this. They may help as an extra aid. If you have a go, let us know next week if you found them helpful

Are they safe? They are much safer than cigarettes. More research is

needed to see whether they are completely safe

Champix

Champix pre-loading

Champix pre-loading

Varenicline acts in two ways Alleviates withdrawal discomfort Reduces ‘reward’ associated with smoking

Current treatment starts 1-2 weeks pre-quit at low dose, makes little use of the second mechanism

What happens if cigs give less satisfaction?

The behaviour should start to ‘extinguish’ – gradual decrease

The cues linked to the sight and smell of cigarettes which normally elicit urges to smoke may weaken as well

After quitting smoking, cigarettes may be missed less and so withdrawal discomfort may be lowered

Champix pre-loading study

Placebo or Champix started 4 weeks pre-quit

All on Champix from 1-week pre-quit

Hajek et al. (2011) Arch Intern Med. 171(8):770-7

Effect on cotinine prior to TQD

Enjoyment of cigarettes

Abstinence

Placebo pre-loading

(n=48)

Varenicline pre-loading

(n=53)

Significance

12 weeksSustained abstinence

21% 47% p=0.005

Conclusion

Varenicline pre-loading seems to facilitate quitting Pre-quit reduction now confirmed in 2 other

trials * Product labelling allows pre-quit use for up

to 5 weeks before TQD

* Hawk et al. Clin Pharmacol Ther. 2012; 91(2):172-80

* Ashare et al. J Psychopharmacol 2012; 26(10): 1383–1390

Champix plus NRT

Champix + NRT

N=116, all on Champix From TQD nicotine or placebo patch No effect of withdrawal ratings or on

abstinence rates Effect possibly on Champix non-reactors?

Hajek et al. (2013) BMC Medicine 11:140

Abstinence (%)

* self-reported

Period after TQD

Placebo Patch (n=59)

Nicotine patch (n=58)

Significance

24 hours 80 79 NS, p = 0.96

1 week 59 69 NS, p = 0.28

4 weeks 59 60 NS, p = 0.91

12 weeks* 29 36 NS, p = 0.39

Tailor Champix dose to response

Tailor Champix dose to response

Increase dose during pre-loading until cig consumption and enjoyment are affected

(‘Non-reactors’ into ‘reactors’) Dose increase not licensed, so limited to

research Study completed, results to be reported

soon and clinical implications covered at Annual Update

Annual Update and Supervision Day: 2013

2. December

Details from Janice Rossabi, sctrp@yahoo.co.uk

Summary

Use the best treatments, not the second best Old NRT:

Pre-loading: Wait for trial results Dose-to-response: Trial needed

New NRT: E-cigs: Use as supplement, follow trial results

Champix: Use pre-loading Dose-to-response: Wait for trial results